Guideline: Test for HBV Before Treating Patients With HCV

Bridget M. Kuehn

September 22, 2016

Before beginning direct-acting antiviral treatment for hepatitis C virus (HCV) infection, patients should be screened for hepatitis B virus (HBV) infection, according to an updated guideline from the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America.

The guideline was updated after case reports of HBV reactivation, and in some cases serious illness, in patients co-infected with HBV and HCV who were being treated with direct-acting antiviral therapy for HCV.

The reports were not confined to one particular regimen of direct-acting antivirals, said Raymond Chung, MD, cochair of the panel that produced the guideline and director of hepatology at Massachusetts General Hospital in Boston. This suggests the reactivation may have to do with a ramp up in HBV replication after HCV clearance, rather than a drug-specific toxicity, he said.

"We think it's a phenomenon due to viral clearing, not a drug toxicity," Dr Chung said.

It is generally recommended that patients with HCV be evaluated for HBV, noted Dr Chung, but often physicians do not follow through with HBV testing. However, in light of the case reports, the panel decided to reiterate the importance of HBV testing before initiating HCV treatment. Vaccination for HBV was also recommended for susceptible individuals.

If individuals with HCV test positive for HBV, physicians should determine whether HBV treatment is warranted, according to the updated guideline. In those patients who meet HBV treatment criteria, treatment for HBV should be initiated before or at the same time as treatment with direct-acting antivirals for HCV.

"The most important thing is that [HBV] be attended to before you get going with [a] course of treatment for [HCV]," Dr Chung said.

Patients with low or undetectable levels of HBV who do not meet the criteria for HBV treatment should be carefully monitored during direct-acting antiviral treatment for co-occurring HCV, the guideline recommends. Dr Chung noted that some patients have developed very serious illness as a result of reactivation, so vigilance is critical.

"The fact of the matter is there is no substitute to being attentive if you decide not to treat or the patient doesn't warrant treatment," he said.

One issue that still hasn't been resolved is what to do with patients who are surface antigen negative for HBV and positive for anti-HBV core antibodies, Dr Chung noted. He explained that those patients are not considered chronically infected. However, there is at least one case report of HBV reactivation in such an individual.

There also are still many questions to be resolved, and more study is needed. For example, Dr Chung noted, it is not yet clear how often HBV reactivations occur in HCV coinfected patients during direct-acting antiviral treatment for HCV, and not all studies have documented these reactivations.

"The data are mixed, and we need much more data collection to fill in the picture, but until then use caution," Dr Chung said.

Dr. Chung reports no direct financial conflicts of interest, but he has received institutional research grants from AbbVie, Bristol-Myers Squibb, Gilead Sciences Inc, Janssen Therapeutics Inc, MassBiologics, and Merck & Co Inc. Disclosures for the full guideline panel are available online.

"HCV Guidance: Recommendations for Testing, Managing, and Treating Hepatitis C." American Association for the Study of Liver Diseases and the Infectious Diseases Society of America. Published online September 16, 2016. Full text

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